GW1-2023-00864_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES I !
Well Contractor Name FROM TO DESCRIPTION
A - 4226
ft. ft.
�- .
NC Well Contractor Certification Number �`"= bJ 'h.,2.,15.OUTER CASING for mulq-cased wells OR LINER if al licable)
GEOLOGIC EXPLORATION /�'�I FROM TO DIAMETER THICKNESS M1tATERIAL
JA I`� f � 7n� ft. ft. in.
Company Name
to _-i J. :�`, ^-� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: :•.:-) j ; 'FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,I�aFiaitFt�'e!c}YL� 0.0 ft' 1 58.0 ft. 1.0 in. SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 ft. 1.0 in' SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 ft' 60.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft. 40.0 ft' 1.0 in. ,010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K if a licabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonmwater Drainage 57.0 ft• 60.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft• 40.0 ft, 20-40 FINE SILICA SAND
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM TO DESCRIPTION color,hardness,sofurock type,grain size,etc.
0.0 ft. 1.0 ft. GRASSITOPSOIL
4.Date Well(s)Completed: 11/22/22 Well ID# BS-23-B/A 10 ft, 22.0 ft. BROWN CLAY
5a.Well Location: 22.0 ft- 50.0 ft- BROWN SILT
GLIDDEN COMPANY 50.0 ft. 60.0 ft. GRAY SILTY PWR
-- - -Facility/Owner Name Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft. ;
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS '
County Parcel Identification No.(PIN) BENTONIfE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
***
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W A411t& �,,, ,,., 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [END 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe oflhis record has been provided to the tveh'owner.
repair under 421 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60.0/40.0 (ft)
For multiple wells list all depths ifdierent(example-3 a 00'mtd 2 r@100D Submit this GW-1 within 30 days of well completion per the following:
40.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If tvater level is above casing,use"+•'
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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